A little girl ten years old was covered from head to foot with scabs and sores, some of which on the body were several centimetres in diameter and looked very ugly. These she had contrived to inflict on herself, in spite of every precaution and admonition. It appeared that successive attacks of measles and of whooping-cough at the age of five had entailed long rest in bed, and had been followed by a tardy convalescence, in the course of which the development of a few pimples on the forehead was the signal for her to commence scratching them and any other part of her body where there was the least discomfort, or where the skin was at all roughened. This merciless self-mutilation ended in the production of large and painful excoriated areas; nevertheless a tic had sprung from the habit, and it remained inveterate.
A little girl ten years old was covered from head to foot with scabs and sores, some of which on the body were several centimetres in diameter and looked very ugly. These she had contrived to inflict on herself, in spite of every precaution and admonition. It appeared that successive attacks of measles and of whooping-cough at the age of five had entailed long rest in bed, and had been followed by a tardy convalescence, in the course of which the development of a few pimples on the forehead was the signal for her to commence scratching them and any other part of her body where there was the least discomfort, or where the skin was at all roughened. This merciless self-mutilation ended in the production of large and painful excoriated areas; nevertheless a tic had sprung from the habit, and it remained inveterate.
Another analogous case is quoted by the same observers[101]:
In this instance, apart from the obvious existence of a confirmed tic, the patient had a curious look about the eyes which a nearer glance showed was caused by complete absence of the eyelashes. He had a trick when speaking or talking of lifting his right hand and running his finger carefully along the margin of the lids, and if it encountered an eyelash projecting beyond the skin, he promptly plucked it out. The endless repetition of this toilette rendered the eyelids barren of lashes.
In this instance, apart from the obvious existence of a confirmed tic, the patient had a curious look about the eyes which a nearer glance showed was caused by complete absence of the eyelashes. He had a trick when speaking or talking of lifting his right hand and running his finger carefully along the margin of the lids, and if it encountered an eyelash projecting beyond the skin, he promptly plucked it out. The endless repetition of this toilette rendered the eyelids barren of lashes.
Are writing tics to be recognised?
Tricks and turns of writing, however ridiculous, involuntary, and ingrained they be, scarcely deserve to be called tics. Those flourishes and ornaments that some people take delight in adding to their letters can no more be considered the expression of a pathological state than the superabundant gestures, the redundant words, the exuberant mimicry, of which others are so prodigal. They are simply modes of exteriorisation peculiar to the individual, and if in their superfluityand excess they go beyond the strict requirements of the case, still, they are only mannerisms of writing or of speech. Their manifestation is rigorously dependent on the performance of some function, and is not preceded by an imperious need of execution.
More akin to the tics is stereotypy of written language, so common an appanage of mental disease. The term is intended to include such habits as repetition of a particular formula, underlining of words, constant use of hyphens in the same way, writing of certain pages in a hand differing from the rest of the manuscript. Séglas[102]has done excellent work in the analysis and interpretation of these troubles. One of his patients used every week to write letters bearing the same complicated address, and signed invariably with the following rigmarole:
De Senez de Mesange, great Prince Napoleon, great Prince of the Blood Royal and Imperial of the Universe, great Admiral, great Marshal of my armies, ... great Procurator of the Republic, Royal and Imperial, great President of the Republic, Royal and Imperial, great Pope, great Duke, great King, great Emperor—Jupiter, Louis XIV. and Louis XV.
De Senez de Mesange, great Prince Napoleon, great Prince of the Blood Royal and Imperial of the Universe, great Admiral, great Marshal of my armies, ... great Procurator of the Republic, Royal and Imperial, great President of the Republic, Royal and Imperial, great Pope, great Duke, great King, great Emperor—Jupiter, Louis XIV. and Louis XV.
Another would write after almost every sentence:
Dieu et son droit, let him be cursed in all that is most cursedqui mal y pense.
Dieu et son droit, let him be cursed in all that is most cursedqui mal y pense.
This was a sort of exorcism, a cabalistic formula enabling the persecuted unfortunate to defend herself against the wiles of the evil spirit.
A tic of writing, however, is of a totally different nature. He who, without pen or pencil, is constrained by irrepressible impulse to go through the movements of writing with his fingers, convulsively, impetuously; and he who, without rhyme or reason, feverishly traces characters utterly at variance with the ideas he wouldexpress, are alike subjects of a writing tic. Of the former, we know no characteristic example, while in the latter case the study of the phenomenon would lead us too far into the realm of automatic writing and graphic impulsions. We must content ourselves with recalling its occurrence in an undeveloped form in the case of O.
Among those who are affected with tics, disorders of writing are very infrequent, even where the tic's exhibition is displayed in the upper extremities. One of the distinctive features of tics, in fact, is the brevity of the interruption they cause in the performance of any voluntary act on the part of the patient. Tics of arm or hand effect but little modification of his writing. He is rarely taken aback by his tic's convulsive demonstration. He can permit the co-existence, on a perfect understanding, of two automatic acts, normal and abnormal, writing and tic.
One of Guinon's patients was wont to proceed in the following way: if asked to write, he would lean on the table, pick up his pen, and just ai it was about to touch the paper, make several little movements of circumduction with his right hand, as a child does. Thereafter, he would sometimes pass on at once to trace the letters; at other times he would have to grind his teeth, contort the right half of his face, put out his tongue, pucker his nose, or dip his pen spasmodically into the ink ten consecutive times—ejaculating ahem! ahem! the while—before being able to commence. He would often cease altogether, to make one or two grimaces, or to wave his hand about. As far as the actual writing was concerned, its distinctness and evenness were no less praiseworthy than its style and content, and though a glance at his gesticulations led one to expect blots and irregularities in his manuscript, he conducted his task with assurance and correctness.
One of Guinon's patients was wont to proceed in the following way: if asked to write, he would lean on the table, pick up his pen, and just ai it was about to touch the paper, make several little movements of circumduction with his right hand, as a child does. Thereafter, he would sometimes pass on at once to trace the letters; at other times he would have to grind his teeth, contort the right half of his face, put out his tongue, pucker his nose, or dip his pen spasmodically into the ink ten consecutive times—ejaculating ahem! ahem! the while—before being able to commence. He would often cease altogether, to make one or two grimaces, or to wave his hand about. As far as the actual writing was concerned, its distinctness and evenness were no less praiseworthy than its style and content, and though a glance at his gesticulations led one to expect blots and irregularities in his manuscript, he conducted his task with assurance and correctness.
Of course, if the tic, whatever it be, exceed a certain limit of frequency and violence, accurate writing may amount almost to a physical impossibility, in which case the patient usually discontinues, although if called on to exercise his will he can always pen a few wordsand even a few lines. However this may be, the spots and scrawls and zigzags and shaky cramped characters we associate with such organic affections as tabes, Friedreich's disease, paralysis agitans, etc., are wholly exceptional in the case of tic.
While, then, disturbances of the function of writing are seldom ascertainable in those who tic, we have convinced ourselves on more than one occasion of the truth of the converse, that the exercise of the faculty is sometimes intimately combined with the evolution of tics of neck and shoulder.
S. dated his mental torticollis from the time when he used to copy figures for several hours a day. As a matter of fact, he wrote an excellent hand, and experienced no difficulty in performing the necessary movements, but continued writing increased the rotation. N.'s torticollis was the sequel to long spells of office work, during which he never laid down his pen. In the case of L., the wryneck and the convulsions of the right arm were preceded by a sort of writers' cramp of the right hand, and subsequently of the left.
In the accompanying instance, the development of which one of us has had the opportunity of observing, the appearance of the torticollis was at first confined to occasions of writing, but gradually it came into evidence with other arm actions, and eventually established itself in a permanent fashion.
P., fifty years old, occupies a responsible position in a big railway company, is director in a large office, and performs his duties with peculiar conscientiousness and zeal. Naturally an emotional man, he was much distressed by an unusually sad family bereavement about the middle of 1900, which coincided with a period of great overwork. As he was obliged every day to arrange innumerable papers and affix his signature to them, he began to notice that each time he wrote his name his head turned to the right involuntarily, and he felt a sensation of discomfort in the neck and right shoulder. He tried to remedy the faulty position by holding his chin with his left hand; nevertheless, in thecourse of the next few months the movement began to assert itself not merely as he wrote his signature, but also when he cut his food at table, or sharpened a pencil, or trimmed his finger nails.October 14, 1901.—Whenever P. proceeds to write, his head is immediately rotated to the right and maintained in that attitude by successive contractions. Simultaneously, the right side of the face is distorted by a grimace, the right eye blinks, and the right corner of the mouth is drawn down by a strong effort of the platysma. The state of affairs is unaltered so long as he is handling a pen, though, curiously enough, his caligraphy itself is flawless. The more firmly he grasps his pen, the more violent the spasms; the substitution of a pencil abates them somewhat, as does writing on the floor with a cane, while if he traces letters in the air in front of him with his finger, they do not occur at all. When both hands are occupied in writing, the head still turns to the right.He was advised to incline his head on his right shoulder as he wrote, and to force his right sternomastoid to contract, in carrying out which instructions he managed to form several hooks and rods correctly without any torticollic movement, and was both elated at the success of the experiment and dejected by the thought of his infirmity. Accordingly all writing was prohibited, all signature making reduced to a minimum, and he was recommended a simple pencil exercise, to be performed with slowness and deliberation while the head was kept in the position just mentioned. Identical rules were to be observed when eating, etc, and a tepid bath was prescribed night and morning.October 21.—Some improvement has taken place. The patient is less uneasy and less discouraged. Dissociation of the movements of writing into their component parts and isolated execution of each are accomplished admirably at the first trial, less well the second, and at the third, rotation recommences. Fatigue rapidly increases, and P. sinks again into impatience, enervation, and despair. Occasionally his anguish is so extreme he is covered with perspiration even after the most elementary pencil drill, and is forced to mop his brows.November 21.—Improvement is maintained. He can now write various letters and short words at his ease, though he still feels uncomfortable in anything requiring a more sustained effort. Otherwise, he is conscious of greater control over his head.December 15.—The amelioration has not persisted. While he was paying a visit to the barber's, and having his hair cut, rotation to the right began again, and when lifting his hat in the street to salute a friend, he repeated the movement. At table, too, he noticed it as he was in the act of bringing his glass to his mouth. P. is consequently upset, and often plunged into tears.December 24.—The patient's condition is more than ever deplorable. On the slightest provocation—indeed, on no provocation at all—furious torsion movements force the head backwards and to the right, while the right shoulder rises.Complete rest in bed was ordered, yet after two or three days of this repose the torticollis manifested itself even in the recumbent position. As a result, he was quite unnerved and talked of suicide. Another physician called in consultation agreed with what had been done, confirmed the integrity of all the reflexes, including the plantars, and recommended a course of electricity.January 20, 1902.—There has been no further change. P. stays abed all morning, inventing endless arrangements of pillows and dictionaries to prop his head. When he goes out for a walk, he turns up the collar of his coat and leans his head on the point of it.January 27.—The electrical treatment has been relinquished. He has also taken one douche at a hydrotherapeutic establishment, but expressed his dissatisfaction and vowed never to return. He then departed to undergo a "water cure" in the country, since when he has vanished entirely from observation.
P., fifty years old, occupies a responsible position in a big railway company, is director in a large office, and performs his duties with peculiar conscientiousness and zeal. Naturally an emotional man, he was much distressed by an unusually sad family bereavement about the middle of 1900, which coincided with a period of great overwork. As he was obliged every day to arrange innumerable papers and affix his signature to them, he began to notice that each time he wrote his name his head turned to the right involuntarily, and he felt a sensation of discomfort in the neck and right shoulder. He tried to remedy the faulty position by holding his chin with his left hand; nevertheless, in thecourse of the next few months the movement began to assert itself not merely as he wrote his signature, but also when he cut his food at table, or sharpened a pencil, or trimmed his finger nails.
October 14, 1901.—Whenever P. proceeds to write, his head is immediately rotated to the right and maintained in that attitude by successive contractions. Simultaneously, the right side of the face is distorted by a grimace, the right eye blinks, and the right corner of the mouth is drawn down by a strong effort of the platysma. The state of affairs is unaltered so long as he is handling a pen, though, curiously enough, his caligraphy itself is flawless. The more firmly he grasps his pen, the more violent the spasms; the substitution of a pencil abates them somewhat, as does writing on the floor with a cane, while if he traces letters in the air in front of him with his finger, they do not occur at all. When both hands are occupied in writing, the head still turns to the right.
He was advised to incline his head on his right shoulder as he wrote, and to force his right sternomastoid to contract, in carrying out which instructions he managed to form several hooks and rods correctly without any torticollic movement, and was both elated at the success of the experiment and dejected by the thought of his infirmity. Accordingly all writing was prohibited, all signature making reduced to a minimum, and he was recommended a simple pencil exercise, to be performed with slowness and deliberation while the head was kept in the position just mentioned. Identical rules were to be observed when eating, etc, and a tepid bath was prescribed night and morning.
October 21.—Some improvement has taken place. The patient is less uneasy and less discouraged. Dissociation of the movements of writing into their component parts and isolated execution of each are accomplished admirably at the first trial, less well the second, and at the third, rotation recommences. Fatigue rapidly increases, and P. sinks again into impatience, enervation, and despair. Occasionally his anguish is so extreme he is covered with perspiration even after the most elementary pencil drill, and is forced to mop his brows.
November 21.—Improvement is maintained. He can now write various letters and short words at his ease, though he still feels uncomfortable in anything requiring a more sustained effort. Otherwise, he is conscious of greater control over his head.
December 15.—The amelioration has not persisted. While he was paying a visit to the barber's, and having his hair cut, rotation to the right began again, and when lifting his hat in the street to salute a friend, he repeated the movement. At table, too, he noticed it as he was in the act of bringing his glass to his mouth. P. is consequently upset, and often plunged into tears.
December 24.—The patient's condition is more than ever deplorable. On the slightest provocation—indeed, on no provocation at all—furious torsion movements force the head backwards and to the right, while the right shoulder rises.
Complete rest in bed was ordered, yet after two or three days of this repose the torticollis manifested itself even in the recumbent position. As a result, he was quite unnerved and talked of suicide. Another physician called in consultation agreed with what had been done, confirmed the integrity of all the reflexes, including the plantars, and recommended a course of electricity.
January 20, 1902.—There has been no further change. P. stays abed all morning, inventing endless arrangements of pillows and dictionaries to prop his head. When he goes out for a walk, he turns up the collar of his coat and leans his head on the point of it.
January 27.—The electrical treatment has been relinquished. He has also taken one douche at a hydrotherapeutic establishment, but expressed his dissatisfaction and vowed never to return. He then departed to undergo a "water cure" in the country, since when he has vanished entirely from observation.
More than once we have had occasion to notice that the degree and extent of such neck and arm convulsions as are provoked or exaggerated by the act of writing vary with the level at which the patient has to write. With elevation of the arm the movements are weak and easily mastered; conversely, lowering of the arm augments them in a marked manner. We repeat, however, that in all these cases the handwriting itself is not interfered with.
It is quite otherwise with writers' cramp, the so-called "graphospasm" or "mogigraphia." This condition is purely and exclusively a disorder of the function of writing, depending for its exhibition on the exercise of this function, else is its existence concealed. For this reason it ought to be differentiated from the tics, although, by its development in obvious neuropathic or psychopathic subjects, it is closely linked to them.
One of Oppenheim's cases was a lady whose husband suffered from paralysis agitans; in her case, fearof becoming affected with the same disease led to the development of writers' cramp. Sometimes it occurs in families, and it may be a concomitant of genuine tics. In spite of the affinity between these two sorts of functional disturbance, we do not feel it incumbent on us to enter on a detailed study of scriveners' palsy in this place.
Tics of the lower limbs are infrequent, and seldom isolated. One of the most habitual of these is the "kicking tic." Sometimes one leg knocks against the other, as in O.'s case, or it is kicked out in front, or to the side, or even backwards, after the manner of a horse. Tonic convulsions of the leg muscles have been observed to give rise to phenomena analogous to tonic tics. Tonic contractions restricted to a particular muscle, or group of muscles, and accompanied by relaxation of the antagonists, have been christened by Ehret[103]"habit contractures" and "habit paralyses." Their characteristic feature is the fact of the contracture being voluntary in origin. For instance, an individual wounds the inner margin of his foot, and learns to escape the pain by throwing his weight on the outer side. Voluntary contraction of the adductors of the foot passes gradually into an involuntary stage, giving place to spasmodic contraction, and the simultaneous inactivity of the antagonists—in this case the peronei—leads ultimately to their atrophy.
In Ehret's view the fact of loss of volitional control argues the psychical nature of the affection, and a similar opinion is held by Thiem, Jacoby, and Wolff, who attribute the analogous cases they report to a sort of traumatic neurosis in which the psychicalelement is preponderant. Needless to remark, the patients in question were not suffering from hysteria.
In this connection ought to be recalled the cases described by Raymond and Janet[104]under the title of "tics of the foot."
The first was a woman thirty-seven years old, who as she walked used slightly to invert her left foot, forcibly dorsiflex the great toe, and separate the remaining toes widely one from the other. Notwithstanding its painful nature, the condition had persisted for seven years, and had originated in a very interesting way. She happened to be undergoing a course of mercurial inunction at the same time as she was troubled with a corn. The idea struck her that perhaps the application of the ointment to the corn might prove efficacious, but while trimming the latter some days later, she had the misfortune to cut herself. Dread of the possible evil effects of the injury was followed on the morrow by an accession of cramps in the foot, the continuance of which led to the deformity that ever since had made walking a misery.The other patient was a young man twenty years of age, whose gait used to be arrested, after a walk of ten minutes, by sudden and vigorous plantar flexion of his right toes. Momentary repose sufficed to make the spasm disappear, but it constantly recurred.
The first was a woman thirty-seven years old, who as she walked used slightly to invert her left foot, forcibly dorsiflex the great toe, and separate the remaining toes widely one from the other. Notwithstanding its painful nature, the condition had persisted for seven years, and had originated in a very interesting way. She happened to be undergoing a course of mercurial inunction at the same time as she was troubled with a corn. The idea struck her that perhaps the application of the ointment to the corn might prove efficacious, but while trimming the latter some days later, she had the misfortune to cut herself. Dread of the possible evil effects of the injury was followed on the morrow by an accession of cramps in the foot, the continuance of which led to the deformity that ever since had made walking a misery.
The other patient was a young man twenty years of age, whose gait used to be arrested, after a walk of ten minutes, by sudden and vigorous plantar flexion of his right toes. Momentary repose sufficed to make the spasm disappear, but it constantly recurred.
Re-education and psychotherapy effected a cure in each instance, so that their psychical nature cannot be called in question, nevertheless the painful character of the affections must not be forgotten, and since the occasions of their manifestation were confined to the act of walking, they correspond rather to "functional" or "professional cramps." In any case, they cannot be confounded with the painful cramps of the calf muscles that characterise certain toxæmias and infections (alcoholism, cholera, etc.).
On the other hand, there can be no doubt of the existence of definite tics of walking—widely varying functional derangements of tonic or clonic type, distinguished by the unexpected interruption of ambulatory rhythm.
We have met with a patient (says Guinon) who would abruptly halt and bend his knees at though he had just received a violent blow on the hock for which he was unprepared. To see him, one would have thought he was about to sink to the ground.
We have met with a patient (says Guinon) who would abruptly halt and bend his knees at though he had just received a violent blow on the hock for which he was unprepared. To see him, one would have thought he was about to sink to the ground.
Such tics of genuflexion are not particularly uncommon. Oddo[105]has recently recorded a very instructive example, whose pathogeny he has been at pains to elucidate.
A little girl, Th., ten years of age, takes four or five perfectly normal paces when she starts to walk, then bends down quickly to the right, flexing her knee to an acute angle and inclining her trunk forward with the deflection of her pelvis, just as a child whose genuflexion in front of an altar has become mechanical by repetition. The performance is sometimes so altogether sudden that Th. actually falls on to her right side. One striking feature of the case is that if she makes a tour of the room in order to be observed at leisure, the inclination never fails to occur at exactly the same point in the circuit—namely, when she is opposite the observer. It is useless formally to interdict her from this routine, for before one has time to notice any irregularity in the gait her knee suddenly flexes at the bidding of an invincible impulse, and a moment later, without any deviation from her path, she has resumed her rhythmical step round the apartment.This movement is not her only one, however. While she lies in bed she can, by flexing her thigh on her pelvis, crack her joints loud enough to be heard, and when she has been up a little while the same action is exhibited. The absence of these cracking sounds during ordinary walking, and their occurrence in the act of genuflexion, very properly explain, as Oddo thinks, the origin of the tic. It seems that the articulations at hip and knee on the right side were affected as the result of successive attacks of scarlatina and diphtheria two years ago, which necessitated a prolonged sojourn in bed, and were accompanied with severe pain. It is interesting to note that the tic made its appearance only after the latter had considerably subsided.Raymond and Janet[106]have reported the case of a young woman who fell on her knees every few paces, rising again with facility and taking a few more steps, to come down on her knees once more with a loud noise. She never did herself any harm, however, and for that matter the accident never occurred on a staircase or in a unsuitable or dangerous spot.
A little girl, Th., ten years of age, takes four or five perfectly normal paces when she starts to walk, then bends down quickly to the right, flexing her knee to an acute angle and inclining her trunk forward with the deflection of her pelvis, just as a child whose genuflexion in front of an altar has become mechanical by repetition. The performance is sometimes so altogether sudden that Th. actually falls on to her right side. One striking feature of the case is that if she makes a tour of the room in order to be observed at leisure, the inclination never fails to occur at exactly the same point in the circuit—namely, when she is opposite the observer. It is useless formally to interdict her from this routine, for before one has time to notice any irregularity in the gait her knee suddenly flexes at the bidding of an invincible impulse, and a moment later, without any deviation from her path, she has resumed her rhythmical step round the apartment.
This movement is not her only one, however. While she lies in bed she can, by flexing her thigh on her pelvis, crack her joints loud enough to be heard, and when she has been up a little while the same action is exhibited. The absence of these cracking sounds during ordinary walking, and their occurrence in the act of genuflexion, very properly explain, as Oddo thinks, the origin of the tic. It seems that the articulations at hip and knee on the right side were affected as the result of successive attacks of scarlatina and diphtheria two years ago, which necessitated a prolonged sojourn in bed, and were accompanied with severe pain. It is interesting to note that the tic made its appearance only after the latter had considerably subsided.
Raymond and Janet[106]have reported the case of a young woman who fell on her knees every few paces, rising again with facility and taking a few more steps, to come down on her knees once more with a loud noise. She never did herself any harm, however, and for that matter the accident never occurred on a staircase or in a unsuitable or dangerous spot.
Leaping tics are met with also.
Sometimes when walking, but more usually when standing quietly, according to Guinon, the patients make little jumps or leaps in their place, looking rather as if they were dancing than really springing into the air. Some actually bound along, others run for a yard or two.
Sometimes when walking, but more usually when standing quietly, according to Guinon, the patients make little jumps or leaps in their place, looking rather as if they were dancing than really springing into the air. Some actually bound along, others run for a yard or two.
Still more bizarre and complex tics have been described, in particular by Gilles de la Tourette. One patient used to commence to run, then kneel suddenly, then rise with equal abruptness. Another was in the habit of stooping down, as if to pick something off the ground, and smartly rising again.
The kinship of these and other similar conditions to the tics is undeniable, and such seems to be the case with the yet more extraordinary phenomena ofjumpingin Maine (Beard),latahamong the Malays (O'Brien),myriachitin Siberia (Hammond). All these affections show, among others, this peculiarity—that unexpected contact produces a spring (Guinon).
In a recent thesis Ramisiray has depicted the dancing mania (ramaneniana) of Madagascar, a condition allied to the latah of the Dutch Indies, but more intimately connected with hysteria, perhaps, and with the saltatory choreas, the saltatory cramps of Bamberger, St. John's and St. Guy's dance, tarentism, etc. The exact nature of these convulsive disorders is stillsub judice, but in any case they present more than a mere resemblance to the tics.
In some tics the palatal muscles are found to contract, but this contraction must not be confused with the spasmodic twitches of the same muscles associated with facial spasm and due to central orperipheral irritation of the seventh nerve. One of us has had occasion to observe an excellent case in point in a young man afflicted with spasm of the orbicularis and zygomatics on the right side, in whom synchronous displacement of the uvula occurred with each twitch. The extreme abruptness and rapidity of the muscular discharges, the inadequacy of voluntary effort to check them, the absolute uselessness of prolonged and systematic treatment, left no doubt as to the accuracy of the diagnosis.
The occurrence of palatal spasm in intracranial lesions has, of course, been recognised—in cerebellar tumour (Oppenheim), in epidemic cerebro-spinal meningitis, in aneurism of the vertebral artery (Siemerling and Oppenheim). It is occasionally associated with the emission of clucking sounds, and with convulsive action of hyoid and tongue muscles. In such cases the distinction between a tic and a spasm is not always easy to establish. We may, however, readily recognise that we are dealing with the former if the contractions of tongue, palate, and larynx are contemporaneous with the execution of a functional act, such as expectoration.
Among those who labour under obsessions, tics of expectoration are well known. One of Guinon's patients, while making forced expirations, used to bring his hand up over his mouth convulsively as though he were afraid of spitting on some one in his neighbourhood.
A case of Séglas', from whom stigmata of hysteria were absent, was possessed, among other things, with the fear of having swallowed certain objects, such as pins, knives, etc. The obsession eventually became so vivid and so intense at certain moments, that it began to be accompanied with a sensation as of a foreign body arrested in the œsophagus, and the anguish thus created revealed itself by various reactions, one of which consisted in excessive salivation and ceaseless expectoration, entailing the carrying about and use of numbers of handkerchiefs.
A case of Séglas', from whom stigmata of hysteria were absent, was possessed, among other things, with the fear of having swallowed certain objects, such as pins, knives, etc. The obsession eventually became so vivid and so intense at certain moments, that it began to be accompanied with a sensation as of a foreign body arrested in the œsophagus, and the anguish thus created revealed itself by various reactions, one of which consisted in excessive salivation and ceaseless expectoration, entailing the carrying about and use of numbers of handkerchiefs.
It is scarcely possible for the mechanism of deglutition, the orderly succession of muscular contractions, to be interfered with by the will, but increased frequency of these movements may constitute an abnormality. Hartenberg's[107]case of deglutition tic was characterised by a continual desire of swallowing saliva; the patient, it is true, was an hysteric.
Rossolimo[108]has called attention to what he distinguishes as amyotaxic troubles of deglutition, a dysphagia of which three types, motor, sensory, and psychic, may be specified. Cases of the last form had already been described by Bechterew.[109]The patient either suffers from a genuine obsession, or is ever at the mercy of an involuntary or even an unconscious dread of choking as he eats, a dread with which he is powerless to cope, though in the case of others the phobia and the dysphagia may alike be intermittent. In the majority of instances there are grave hereditary or personal neuropathic antecedents.
Some people are afflicted with eructations so continual that they amount to tics. One of us is acquainted with a family several of whose members present this peculiarity in different degrees, yet none of them suffers from hysteria.
Otto Lerch[110]has published a case of multiple tics, among which may be enumerated opening and closing the eyes, rolling of the ocular globes, tilting back of the head, with instantaneous recovery of position, inclination of the whole trunk to right or left—each and all of which movements are frequently attended,especially at night and in the morning, by profound eructations.
Of course, the prominent place occupied by these signs in hysteria is well recognised: the demonologues of old regarded them as an index of the departure of the devils that dwelt in the possessed. In a case of hysteria that came under the notice of Raymond and Janet,[111]a general tremulousness of the whole body was replaced by a chorea of the right arm, which in its turn was succeeded by the perpetual emission of sonorous eructations. In another instance[112]inspiratory hiccoughs and expiratory eructations co-existed. A similar example is cited by Cruchet in his thesis.
In the same category of facts are included those to which the name ofaerophagic tichas been applied. Various cases have been narrated by Pitres and by Séglas,[113]the latter of whom, in a remarkably complete analysis of the condition, has demonstrated its identity with the tics, and written very instructive commentaries on his observations.
I was consulted (says Séglas) by a man thirty-four years of age, who was sent to me as a hypochondriacal neurasthenic. No sooner had he entered my consulting-room than I was astonished to find he was giving vent to repeated sonorous eructations at very brief intervals. His story was to the effect that several weeks previously he had been suddenly seized in the middle of a meal by a sort of vertigo, and had lost consciousness. A consideration of subsequent events made it more than probable that he had had an ictus; the patient, however, was for no apparent reason persuaded that he had been poisoned by badly cooked food, and from that moment became despondently preoccupied with the state of his stomach. A few days later the eructations made their appearance.A closer examination very soon dispelled the idea of their gastric origin, seeing that the digestive functions were in every respect normal, whereas the symptom in question occurred at any moment, independentlyof the stage of digestion, and the gases evolved were absolutely inodorous. On the other hand, one could easily satisfy oneself that the eructations were preceded by an inspiratory effort and by two or three very obvious movements of deglutition, accompanied by a low, rumbling, pharyngeal noise, and followed almost immediately by the expulsion of gas. Their reproduction several times a minute was spasmodic in character and irregular in rhythm, and continued, it might be, for hours.Of this series of phenomena the patient had conscious knowledge only of the last—viz. the eructations—and affirmed their involuntary nature and his desire to be rid of them.The influence exerted on them by various circumstances is worthy of notice. Any emotion, or any reference on the part of the patient to the condition of his stomach, tended to exaggerate them, while, inversely, it was remarked by his wife that the distraction of conversation, or of a promenade, or of musical séances—to which he was passionately devoted—served to banish them instantaneously and for as long as the distraction endured. Sleep suspended their activity, but at any interruption of it they scarcely ever failed to reassert themselves.These considerations determined my view of his trouble as a peculiar form of tic, which consisted in "muscular spasms systematically harmonised to produce the alternating deglutition and expulsion of a certain quantity of atmospheric air" (Pitres), which therefore might be denominated anaerophagic tic.
I was consulted (says Séglas) by a man thirty-four years of age, who was sent to me as a hypochondriacal neurasthenic. No sooner had he entered my consulting-room than I was astonished to find he was giving vent to repeated sonorous eructations at very brief intervals. His story was to the effect that several weeks previously he had been suddenly seized in the middle of a meal by a sort of vertigo, and had lost consciousness. A consideration of subsequent events made it more than probable that he had had an ictus; the patient, however, was for no apparent reason persuaded that he had been poisoned by badly cooked food, and from that moment became despondently preoccupied with the state of his stomach. A few days later the eructations made their appearance.
A closer examination very soon dispelled the idea of their gastric origin, seeing that the digestive functions were in every respect normal, whereas the symptom in question occurred at any moment, independentlyof the stage of digestion, and the gases evolved were absolutely inodorous. On the other hand, one could easily satisfy oneself that the eructations were preceded by an inspiratory effort and by two or three very obvious movements of deglutition, accompanied by a low, rumbling, pharyngeal noise, and followed almost immediately by the expulsion of gas. Their reproduction several times a minute was spasmodic in character and irregular in rhythm, and continued, it might be, for hours.
Of this series of phenomena the patient had conscious knowledge only of the last—viz. the eructations—and affirmed their involuntary nature and his desire to be rid of them.
The influence exerted on them by various circumstances is worthy of notice. Any emotion, or any reference on the part of the patient to the condition of his stomach, tended to exaggerate them, while, inversely, it was remarked by his wife that the distraction of conversation, or of a promenade, or of musical séances—to which he was passionately devoted—served to banish them instantaneously and for as long as the distraction endured. Sleep suspended their activity, but at any interruption of it they scarcely ever failed to reassert themselves.
These considerations determined my view of his trouble as a peculiar form of tic, which consisted in "muscular spasms systematically harmonised to produce the alternating deglutition and expulsion of a certain quantity of atmospheric air" (Pitres), which therefore might be denominated anaerophagic tic.
Different varieties of this tic exist, according as the air swallowed is derived from the exterior or from the lung, and depending on its penetration into the stomach or simply into the pharyngo-œsophageal canal; and further, the physiological mechanism of the condition varies with them.
Let us suppose that the swallowed air comes from the lung. In this case, a certain quantity of air is imprisoned at the beginning of expiration in the pharyngo-œsophageal cavity, whose orifices are firmly closed by simultaneous contraction of the muscles of the palate, glottis, and base of the tongue. At this moment a brisk contraction of the constrictors of the pharynx drives the accumulated air out by the mouth, setting the membranes surrounding the supero-anterior opening of the cavity into vibration in so doing, whereby the air escapes as a more or less noisy eructation.Should the mouth not open at this juncture, however, the air is compressed and crowded back into the lower part of the œsophagus, whence it passes through the easily dilatable cardiac ring into the stomach,to be expelled again by the mouth in the same noisy way once it has accumulated in sufficient quantity.The deglutition of external air is preceded by an aspiratory thoracic effort; closure of the glottis forces the œsophagus to open under the stress of increased negative intrathoracic pressure, and to suck air down. When aspiration ceases, this air is either driven out forthwith, or gathered in the stomach, as we have just seen.One may sometimes notice that the act of suction is succeeded by movements of swallowing, in which case the probability is that at the moment of aspiration the closure both of glottis and of pharynx prevents the penetration of atmospheric air into either the trachea or the gullet, in spite of the differences of pressure, and that these movements allow its passage through the œsophagus.
Let us suppose that the swallowed air comes from the lung. In this case, a certain quantity of air is imprisoned at the beginning of expiration in the pharyngo-œsophageal cavity, whose orifices are firmly closed by simultaneous contraction of the muscles of the palate, glottis, and base of the tongue. At this moment a brisk contraction of the constrictors of the pharynx drives the accumulated air out by the mouth, setting the membranes surrounding the supero-anterior opening of the cavity into vibration in so doing, whereby the air escapes as a more or less noisy eructation.
Should the mouth not open at this juncture, however, the air is compressed and crowded back into the lower part of the œsophagus, whence it passes through the easily dilatable cardiac ring into the stomach,to be expelled again by the mouth in the same noisy way once it has accumulated in sufficient quantity.
The deglutition of external air is preceded by an aspiratory thoracic effort; closure of the glottis forces the œsophagus to open under the stress of increased negative intrathoracic pressure, and to suck air down. When aspiration ceases, this air is either driven out forthwith, or gathered in the stomach, as we have just seen.
One may sometimes notice that the act of suction is succeeded by movements of swallowing, in which case the probability is that at the moment of aspiration the closure both of glottis and of pharynx prevents the penetration of atmospheric air into either the trachea or the gullet, in spite of the differences of pressure, and that these movements allow its passage through the œsophagus.
Aerophagia is by no means, therefore, a simple involuntary movement, but a combination of systematised muscular actions. In fact, it is a tic, and as such has both a physical and a psychical side.
From the material point of view (to quote Séglas again), the predominant symptom is the eructation, and the object in determining the accessory symptoms is to distinguish it from gastric eructations properly so called, the consequence of improper fermentation. In our case the appetite is good, and the digestion normal—tympanites, splashing, and abdominal pain are all absent. The gases evolved are inodorous, and their analysis in different cases (Ponagen, Hoppe-Seyler, Pitres, Sabrazès and Rivière) has shown that so far from containing any abnormal constituent, they have almost the same composition as atmospheric air. Application of the ear to the vertebral column at the level of the stomach enables one to detect a noise that appears to correspond to the passage of air into that viscus, and less than a second later comes the eructation.Facts of another kind indicate the participation of a psychical element. The activity of the tic increases under the influence of the emotions and decreases or disappears momentarily at the bidding of the will. Distraction, concentration of the attention on some particular thing, speaking, reading aloud, are also calculated to suspend its manifestations. In some cases, especially where there is an association with hysteria, support is given to the theory of its psychical origin by the observation that prolonged opening of the mouth, and the administration of mica panis pills or of distilled water tinted with methylene blue, have had a definite effect in controlling the spasm (Pitres). Moreover, the co-existence or pre-existence of intellectual troubles or mental peculiarities is often incontrovertibly proved by a painstaking psychological examination.In reality this aerophagic tic is a symptom-complex encountered invery different pathological conditions. No doubt its frequency is greatest and its development highest in hysteria, but we are in error if we suppose that it is the exclusive appurtenance of that disease: its occurrence in our case of general paralysis is evidence to the contrary. I have noted it where there was not the slightest suspicion of hysterical antecedents. Nevertheless its relation to pathological mental states of some form or another is invariable.
From the material point of view (to quote Séglas again), the predominant symptom is the eructation, and the object in determining the accessory symptoms is to distinguish it from gastric eructations properly so called, the consequence of improper fermentation. In our case the appetite is good, and the digestion normal—tympanites, splashing, and abdominal pain are all absent. The gases evolved are inodorous, and their analysis in different cases (Ponagen, Hoppe-Seyler, Pitres, Sabrazès and Rivière) has shown that so far from containing any abnormal constituent, they have almost the same composition as atmospheric air. Application of the ear to the vertebral column at the level of the stomach enables one to detect a noise that appears to correspond to the passage of air into that viscus, and less than a second later comes the eructation.
Facts of another kind indicate the participation of a psychical element. The activity of the tic increases under the influence of the emotions and decreases or disappears momentarily at the bidding of the will. Distraction, concentration of the attention on some particular thing, speaking, reading aloud, are also calculated to suspend its manifestations. In some cases, especially where there is an association with hysteria, support is given to the theory of its psychical origin by the observation that prolonged opening of the mouth, and the administration of mica panis pills or of distilled water tinted with methylene blue, have had a definite effect in controlling the spasm (Pitres). Moreover, the co-existence or pre-existence of intellectual troubles or mental peculiarities is often incontrovertibly proved by a painstaking psychological examination.
In reality this aerophagic tic is a symptom-complex encountered invery different pathological conditions. No doubt its frequency is greatest and its development highest in hysteria, but we are in error if we suppose that it is the exclusive appurtenance of that disease: its occurrence in our case of general paralysis is evidence to the contrary. I have noted it where there was not the slightest suspicion of hysterical antecedents. Nevertheless its relation to pathological mental states of some form or another is invariable.
It is often found in cases of insanity of the obsessional or of some other type.
I have had an opportunity (says Séglas) of observing an instance of aerophagia in a woman of fifty-four years, who for the last fifteen years has been suffering from hypochondriasis in a delusional form. She believes she has a hole in her head, and that her brain is gangrenous; she is no longer conscious of her body, nor of her food as it passes through. "It is like a cupboard empty of everything but air." Grafted on this delusion is an aerophagic tic, upon which the patient relies in support of her contentions. So little is she able to withstand its ceaseless repetition that the sequence of muscular actions continues though the tongue be held outside the mouth or fixed with a spoon.I have seen the same phenomenon in another woman, forty-six years of age, afflicted with fixed and systematised delusions of persecution. She imagined that she was being pursued by sorcerers, who had cast a spell on her and were about to poison her, torture her, break her on the wheel, etc. In addition to very distinct and frequent verbal hallucinations and disorders of general sensibility, she exhibited several tics, one of which consisted in spasmodically closing her eyes, brandishing her right arm, and uttering a string of incomprehensible words; the other was this aerophagic tic, characterised by a jumble of quick swallowing movements, pharyngeal grunts, and long-drawn-out, sonorous eructations. All this performance was rehearsed two or three times a minute as a sort of convulsive discharge, which she alleged the sorcerers forced her to emit in spite of herself, exactly as they coerced her into uttering a jargon she did not understand, and wagged her tongue at their own sweet will.
I have had an opportunity (says Séglas) of observing an instance of aerophagia in a woman of fifty-four years, who for the last fifteen years has been suffering from hypochondriasis in a delusional form. She believes she has a hole in her head, and that her brain is gangrenous; she is no longer conscious of her body, nor of her food as it passes through. "It is like a cupboard empty of everything but air." Grafted on this delusion is an aerophagic tic, upon which the patient relies in support of her contentions. So little is she able to withstand its ceaseless repetition that the sequence of muscular actions continues though the tongue be held outside the mouth or fixed with a spoon.
I have seen the same phenomenon in another woman, forty-six years of age, afflicted with fixed and systematised delusions of persecution. She imagined that she was being pursued by sorcerers, who had cast a spell on her and were about to poison her, torture her, break her on the wheel, etc. In addition to very distinct and frequent verbal hallucinations and disorders of general sensibility, she exhibited several tics, one of which consisted in spasmodically closing her eyes, brandishing her right arm, and uttering a string of incomprehensible words; the other was this aerophagic tic, characterised by a jumble of quick swallowing movements, pharyngeal grunts, and long-drawn-out, sonorous eructations. All this performance was rehearsed two or three times a minute as a sort of convulsive discharge, which she alleged the sorcerers forced her to emit in spite of herself, exactly as they coerced her into uttering a jargon she did not understand, and wagged her tongue at their own sweet will.
To quote Séglas again in conclusion:
The air-swallowing tic is merely a syndrome common to various pathological conditions differing widely enough, but all alike in being associated with some degree of mental impairment, in which perhaps may be discovered the actual cause of the condition. It cannot therefore be looked upon as a simple spasm, based anatomically on a reflex arc, but must be regarded as a reaction whose substratum is a cortico-spinal anastomosis—that is to say, it is a tic.
The air-swallowing tic is merely a syndrome common to various pathological conditions differing widely enough, but all alike in being associated with some degree of mental impairment, in which perhaps may be discovered the actual cause of the condition. It cannot therefore be looked upon as a simple spasm, based anatomically on a reflex arc, but must be regarded as a reaction whose substratum is a cortico-spinal anastomosis—that is to say, it is a tic.
Tics of vomiting may be produced if the diaphragm be affected. Noguès and Sirol[114]have reported the case of a woman with a pharyngo-laryngeal derangement resembling vomiting, except as far as the actual ejection of alimentary matters was concerned. She used to become conscious of a sensation of constriction, and to feel the tickling of a foreign body in the gullet; at this point the slightest pressure on the neck provoked a convulsive attack, in which all the pantomime of vomiting was gone through without the actual emesis taking place.
It is possible, as Noguès and Sirol think, that the trouble may have originated in a reflex spasm, and that with the disappearance of the primary irritation a new psychical factor operated to effect its repetition and prolongation.
The designation of all these functional disorders as tics is not always justifiable, and their separation from the corresponding normal act is frequently a task of delicate diagnosis, but patient search for the exciting cause and study of the concomitant mental anomalies will supply the necessary indications.
Respiratory tics are exceedingly numerous. They concern the diaphragm and the muscles of inspiration or expiration, and are accompanied by synergic movements of the muscles of the nose, lips, tongue, palate, pharynx, as well as by laryngeal noises or by tics of the face and limbs. They embody disturbances of various functional acts, and may be subdivided into inspiratory and expiratory tics.
It is only as regards their frequency that such reflex mechanisms as yawning and sneezing are liable to be modified by the intervention of the will. Saenger[115]records the case of a woman twenty-nine years old, not affected with hysteria, who used to suffer from attacks of yawning and of stiffness in the arms, followed by rapid contractions of the tongue lasting for about a minute. He describes the condition as one of "idiopathic spasm"—probably a species of tic. It is in hysteria, however, that functional variations in sneezing and yawning are most commonly found, and the latter, moreover, may constitute the aura of an epileptic fit. Yawning occurs in a most intractable form in meningeal affections, and in cerebral and cerebellar tumours.
"Rhincho-spasm," a snoring tic, has been observed by Oppenheim in a case of neurofibromatosis. In certain tics of this nature, and in sniffing tics, the onset is sometimes attributable to the presence of adenoids.
Among various expiratory tics may be enumerated the habit of blowing through one's nose or mouth. Schapiro has reported a case of expiratory "spasm" due to contraction of the buccinators. Whistling ought to be considered a stereotyped act, rather than a tic, as Letulle maintains.
Spasmodic troubles of respiration, defined indifferently as "spasmodic dyspnœa," "spasmodic asthma," "spasmodic cough," "asphyxial spasm," "nervous cough," etc., ought not to be classified as tics; in many cases they are genuine spasms, arising from some irritation in sensory paths. At the instant of any contact, or under the influence of a sudden noise or a bright light, a patient of Edel's used to become distressingly dyspnœic. Evidently the condition was one of spasm.
Coughing tics also are of remarkably commonoccurrence. Many individuals ceaselessly interrupt the thread of their conversation to make more or less audible explosive expirations, for which there is neither reason nor necessity, since the respiratory paths are free from all irritation or obstruction. These useless little coughs do not always deserve the appellation of tics; in many instances they are mannerisms comparable to the gestures of conversation or reflection, although in some people their insistence, abruptness, and irresistibility might justify their incorporation in the other category. Their co-existence with tics of face and limbs has been noted, as in a case published by Tissié[116]of an eight-year-old child, with ocular and facial tic and spasmodic cough.
Clonic contraction of the diaphragm gives rise to conditions imitated or caricatured by the tics, in particular sobbing and hiccoughing. It must not, of course, be forgotten that these are apt to occur in hysteria, as well as in organic disease of the nervous system, and in grave infectious states. Careful and searching inquiry must therefore precede any expression of diagnosis.
Tonic diaphragmatic contraction is of very much greater rarity. In such cases abdominal respiration comes to a momentary standstill, whereas thoracic respiration is accelerated. The patient is in imminent danger of being asphyxiated, and the insertions of the diaphragm sometimes become painful. What is known as acute pulmonary eructation is occasionally the sequel to this convulsive affection. Tonic contraction of the diaphragm is nearly always of an hysterical nature, and is doubtless akin to the aerophagic type.
INmovements of inspiration or of expiration the passage of air through a more or less contracted glottis gives rise to all sorts of sounds, some of which, under certain conditions, must be included in the category of tics.
The most elementary of these, and at the same time the most common (says Guinon), is the involuntary exclamation. In the midst of his tics and grimaces, a cry—ah!—escapes the patient's lips at intervals, a shrill, sudden, and momentary cry which interrupts his talk, or breaks in on a period of silence, and which he repeats only once or perhaps several times in succession. The thread of his conversation, nevertheless, is seldom if ever discontinuous, and his audience is witness of its rationality and accuracy of expression. Rather more complicated is the ejaculation "ouah!" Sometimes one meets with noises that are faithful reproductions of the sounds emitted by various animals.
The most elementary of these, and at the same time the most common (says Guinon), is the involuntary exclamation. In the midst of his tics and grimaces, a cry—ah!—escapes the patient's lips at intervals, a shrill, sudden, and momentary cry which interrupts his talk, or breaks in on a period of silence, and which he repeats only once or perhaps several times in succession. The thread of his conversation, nevertheless, is seldom if ever discontinuous, and his audience is witness of its rationality and accuracy of expression. Rather more complicated is the ejaculation "ouah!" Sometimes one meets with noises that are faithful reproductions of the sounds emitted by various animals.
Guinon is disposed to exclude such simple involuntary explosions as "ahem! ahem!" from the tics, though he admits the analogy to them. He says the sound exactly resembles the trifling little clearance of the throat which is repeated a thousand times a day by people suffering from chronic angina. We, however, are inclined to look upon it as an ordinary spasmodic reaction evoked by some laryngeal or pharyngeal irritation, which in spite of the removal of the latter continues to take place, and because of its meaningless repetition is fairly to be classed as a tic. All that we have said of blinking, for instance, is applicable in this connection.
Of course the embellishment of one's discourse withmore or less audible expirations is of frequent occurrence: the hesitating eh ... eh ... to which children give vent in the recitation of their lessons is not confined to them alone. It can scarcely be maintained that these laryngeal noises are tics, since their production is coincident with the exercise of the faculty of speech; hence they are not unlike "functional cramps." On the other hand, the unexpected bark or gurgle that breaks the silence is a pure tic of phonation.[117]Those who suffer in this way reveal characteristic stigmata in the immediateness of the compelling idea and the exaggerated nature of the subsequent satisfaction. To unravel the intricacies of the origin of these tics is a matter of considerable difficulty, though probably imitation is not without influence in their genesis. Reference will be made later to a tic of this kind attributed by Charcot to imitation.
Among the insane similar cries are often the outcome of delusions. At the Congress of Limoges a case was reported by Briand of an old man who imagined himself transformed into a clock and swung his arms with pendulum-like regularity, indicating the hours by uttering raucous sounds at the proper intervals. However curious these sounds were, the fact of their being appropriate is decisive against their classification as tics.
Unmistakable tics of speech, however, do occur.
Speech is a complex of different muscular acts, and, being so, is liable to be disarranged in various ways, by defect in respiration, phonation, articulation, even in ideation. Organic affections aside, it is inadmissible to describe as tics each and all of the functional disturbances of speech that are not based on any discoverable material lesion of nerve centres. One must in fact distinguish between troubles of speechconfined to occasions when the faculty is in operation and those that consist in not merely useless but inopportune utterance. However arduous it may occasionally be to draw this distinction, however common the occurrence of transitional forms, it has the advantage of limiting the scope of the term "tic of language." To the latter category only can the description be applied.
For this reason we think it preferable to exclude stammering, stuttering, and all defects of phonation or articulation whose existence is revealed only in the act of speaking. At the same time reference must be made to facts linking these functional anomalies to the tics, and to instances of the latter existing with or succeeding the former.
Such is the case with stammering.
According to Letulle,[118]stammering is a tic of speech whose beginning is a functional disturbance of nervous centres, as is that of tics in general. Holding as we do, however, that one of the features of tic is its appearance in season and out of season, we cannot class stammering as a tic, since its exhibition is restricted to the exercise of a certain function, viz. speech. It is therefore comparable to a "professional cramp," and we may briefly note the analogies it offers to the tics.
Stammering,[119]which in more than fifty per cent. of cases is hereditary, and associated with a neuropathic diathesis, usually betrays itself in childhood and becomes aggravated at puberty. The old idea which credited stammerers with exceptional intellectual powers, in whom, however, rapidity of thought surpassed rapidity of action on the part of the muscles of articulation,is exploded, and to-day those thus afflicted are assigned their true place among the volitionally infirm. In a few rare cases stammering has been due to organic disease of the centres for articulate speech, or of bulbo-pontine nuclei; it has been supposed also to result from genuine spasm on a reflex arc, and this is a possible explanation; as a general rule, however, the pathogeny of stammering is identical with that of tic. Its dependence on such affections of nose, larynx, and pharynx as hypertrophic rhinitis and adenoids has been emphasised by Biaggi[120]; and Derevoge,[121]in directing attention to the association of volitional enfeeblement with respiratory troubles, remarks that stammerers sometimes have a phobia for certain words. Many observers have been convinced of the psychical nature of the affection from the fact of its disappearance during singing, as well as from the effect anger, elation, and other stimuli have in momentarily inhibiting it. The same is of course true of the tics.
Further, little attempt is made either by thetiqueuror the stammerer to correct his failing, so that prognosis improves with the adoption of systematic treatment. Stammering is a functional anomaly; it is a derangement of respiration, phonation, and articulation. However normal be the movements of lips and throat in the execution of certain acts, they are far from being normal in the exercise of speech. As a preliminary to speaking the stammerer clenches his teeth and approximates his lips, thus effectually preventing the inrush of air except by the nares; simultaneously he contracts his tongue and obstructs the isthmus of the pharynx, while the glottis also may close spasmodically. Then he abruptly expands his thorax and inhales aconsiderable quantity of air, yet is he ever on the verge of breathlessness, for he cannot voluntarily arrest himself, or make a break between two respirations. He seeks to continue speaking though his lungs are empty of air; he cannot control expiration by antagonistic contraction of inspiratory muscles; often he finds himself unable to commence speaking at all.
The glottis is either open, allowing the silent escape of air, or it is completely occluded. In the midst of syllables or words the voice is frequently "cut" by a sudden halt indicative of spasmodic closure of the glottis. A contrast to the ease with which vowels are pronounced is provided by the difficulty experienced in the enunciation of various consonants. Convulsive movements of the lips frustrate the endeavour to form the series of successive positions which the consonants demand.
An association of stammering with convulsive phenomena of a different nature has often been remarked. Instances of this have been given by Janke.[122]One patient takes a few paces backward, limping with his left leg till he finds something to give him support, and knocking his shoulder several times against wall or furniture, as soon as he encounters it; if he is seated he rises slowly from the chair, holding it with his hands the while, and forthwith falls back into his seat in order to begin. Another taps his fingers on his thigh whenever the word he is about to utter commences with "g" or "k."
In Brissaud's clinique we have met with a couple of instructive cases: